| NPI | 1164555769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA19714) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 270) |
| 363A00000X Physician Assistant (Licence: WA PA 10003212) | |
| 363AM0700X Physician Assistant, Medical (Licence: CA PA19714) | |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA10003212) | |
| Enumeration Date | 2007-03-13 |
| Last Update Date | 2016-02-02 |