| NPI | 1992391627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61313035) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA2431) |
| Enumeration Date | 2020-12-16 |
| Last Update Date | 2025-04-24 |