NPI | 1164581849 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA167) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA pa10004704) |
Enumeration Date | 2006-12-08 |
Last Update Date | 2021-09-01 |