| NPI | 1174793590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60109612) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: OR PA01360) |
| 363AS0400X Physician Assistant Surgical (Licence: WA PA60109612) | |
| Enumeration Date | 2008-03-03 |
| Last Update Date | 2020-12-04 |