| NPI | 1194770206 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA60600205) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 1566) |
| 363AM0700X Physician Assistant, Medical (Licence: OR PA180010) | |
| Enumeration Date | 2006-05-24 |
| Last Update Date | 2017-01-10 |