| NPI | 1811223423 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 14189228-1206) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA60149513) |
| 363A00000X Physician Assistant (Licence: WA PA60149513) | |
| Enumeration Date | 2009-11-02 |
| Last Update Date | 2025-11-17 |