| NPI | 1972865582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60299976) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 138797) |
| Enumeration Date | 2012-06-10 |
| Last Update Date | 2023-11-02 |