| NPI | 1164462990 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA01048) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60041664) |
| Enumeration Date | 2006-06-08 |
| Last Update Date | 2020-11-06 |