| NPI | 1821415175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: WA PA60548104) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085005003) |
| Enumeration Date | 2014-03-25 |
| Last Update Date | 2021-05-05 |