| NPI | 1780451492 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA.PA.61637735) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL 9118229) |
| Enumeration Date | 2023-12-04 |
| Last Update Date | 2026-05-15 |