| NPI | 1174517627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9104179) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10004773) |
| Enumeration Date | 2005-09-09 |
| Last Update Date | 2009-05-19 |