| NPI | 1104092758 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA61021806) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MP 106) |
| Enumeration Date | 2008-05-05 |
| Last Update Date | 2024-02-29 |