| NPI | 1225381130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA 60509731) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 5224) |
| Enumeration Date | 2012-10-17 |
| Last Update Date | 2017-03-14 |