| NPI | 1972903458 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60815222) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: WA LP60080597) |
| 171000000X Military Health Care Provider (Licence: 1145181) | |
| Enumeration Date | 2014-09-03 |
| Last Update Date | 2020-12-10 |