| NPI | 1003191065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60647532) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60647532) |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA60647532) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 014405) | |
| Enumeration Date | 2011-10-20 |
| Last Update Date | 2016-11-30 |