| NPI | 1154722692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60996895) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: HI AMD661) |
| Enumeration Date | 2014-09-15 |
| Last Update Date | 2019-11-19 |