| NPI | 1073062808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12016) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA 60678965) |
| Enumeration Date | 2016-09-21 |
| Last Update Date | 2022-08-26 |