| NPI | 1215960372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA pa10003610) |
| 363AS0400X Physician Assistant, Surgical (Licence: WA PA10003610) | |
| Enumeration Date | 2006-07-09 |
| Last Update Date | 2021-03-30 |