| NPI | 1861040206 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13522) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61226812) |
| Enumeration Date | 2019-08-28 |
| Last Update Date | 2023-09-22 |