| NPI | 1053368340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA00610) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10004163) |
| Enumeration Date | 2006-05-30 |
| Last Update Date | 2021-02-04 |