| NPI | 1043503659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60585304) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5196) |
| 363A00000X Physician Assistant (Licence: ID PA893) | |
| 363A00000X Physician Assistant (Licence: OR PA165793) | |
| Enumeration Date | 2011-05-16 |
| Last Update Date | 2020-03-17 |