| NPI | 1174693154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 0001044) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10004817) |
| Enumeration Date | 2006-11-08 |
| Last Update Date | 2019-10-21 |