| NPI | 1205951290 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60205857) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA154047) |
| 363A00000X Physician Assistant (Licence: AK PADT2346) | |
| Enumeration Date | 2007-03-20 |
| Last Update Date | 2023-06-01 |