| NPI | 1922164953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA-60561046) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: military) |
| Enumeration Date | 2006-12-27 |
| Last Update Date | 2019-04-09 |