| 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 |