| NPI | 1780259945 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2181) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61569778) |
| Enumeration Date | 2021-05-20 |
| Last Update Date | 2024-07-15 |