| NPI | 1073021200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60882779) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA TA60888612) |
| Enumeration Date | 2018-01-23 |
| Last Update Date | 2018-10-16 |