| NPI | 1003149147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60842563) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA3852) |
| 363A00000X Physician Assistant (Licence: TN PA2786) | |
| Enumeration Date | 2009-09-08 |
| Last Update Date | 2023-03-29 |