| NPI | 1770289621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2450) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA6140460) |
| 363A00000X Physician Assistant (Licence: OR PA219548) | |
| Enumeration Date | 2023-02-02 |
| Last Update Date | 2024-09-27 |