| NPI | 1942090592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA70004090) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1210273) |
| Enumeration Date | 2025-05-07 |
| Last Update Date | 2025-07-21 |