| NPI | 1104812981 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61281463) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA 01014) |
| Enumeration Date | 2005-09-27 |
| Last Update Date | 2022-08-01 |