| NPI | 1134378169 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60055084) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ID PA-767) |
| Enumeration Date | 2008-09-15 |
| Last Update Date | 2021-04-16 |