| NPI | 1134308067 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60021277) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 1187) |
| Enumeration Date | 2007-10-27 |
| Last Update Date | 2012-09-04 |