| NPI | 1760847057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA179531) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61101176) |
| Enumeration Date | 2015-12-31 |
| Last Update Date | 2025-03-11 |