| NPI | 1144753518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA 60988491) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA56263) |
| Enumeration Date | 2017-04-04 |
| Last Update Date | 2019-10-16 |