| NPI | 1073056511 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60708783) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9109961) |
| Enumeration Date | 2016-12-01 |
| Last Update Date | 2020-11-12 |