| NPI | 1023378882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WA 60697705) |
| Enumeration Date | 2012-05-25 |
| Last Update Date | 2019-01-07 |