| NPI | 1942686639 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61285753) | 
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WA A160110760) | 
| Enumeration Date | 2015-08-04 | 
| Last Update Date | 2025-01-09 |