| NPI | 1770213761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: WA ES60317745) |
| Enumeration Date | 2022-06-14 |
| Last Update Date | 2022-11-10 |