| NPI | 1053492421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA 10005151) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WI 491) |
| 363A00000X Physician Assistant (Licence: WA PA10005151) | |
| Enumeration Date | 2006-10-18 |
| Last Update Date | 2015-05-04 |