| NPI | 1831579515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 8195) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA 60721868) |
| Enumeration Date | 2015-06-08 |
| Last Update Date | 2025-03-03 |