| NPI | 1063851889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1551) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: WA PA60379809) | |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA60379809) | |
| Enumeration Date | 2013-06-14 |
| Last Update Date | 2020-08-12 |