| NPI | 1962833152 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61610365) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1108139) |
| Enumeration Date | 2013-12-12 |
| Last Update Date | 2026-01-27 |