| NPI | 1972031698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61047355) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085006213) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2017-05-25 |
| Last Update Date | 2022-07-21 |