| NPI | 1225107089 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60475541) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9103177) | |
| 363AS0400X Physician Assistant, Surgical (Licence: OR PA00601) | |
| Enumeration Date | 2006-11-07 |
| Last Update Date | 2021-08-23 |