| NPI | 1215997713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110840194) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10004700) |
| 363AS0400X Physician Assistant, Surgical (Licence: VA 0110840194) | |
| Enumeration Date | 2006-03-27 |
| Last Update Date | 2022-04-01 |