| NPI | 1053773309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60630963) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60630963) |
| 363AS0400X Physician Assistant, Surgical (Licence: WA TA60638390) | |
| Enumeration Date | 2016-03-25 |
| Last Update Date | 2021-06-22 |