| NPI | 1922546027 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60892458) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-1472) |
| Enumeration Date | 2017-02-08 |
| Last Update Date | 2021-05-04 |