| NPI | 1174692198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: WA PA10004470) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA 10004470) |
| Enumeration Date | 2006-11-06 |
| Last Update Date | 2011-09-01 |