| NPI | 1235205857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA 60356641) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: SC NCCPA 1066157) |
| Enumeration Date | 2006-11-27 |
| Last Update Date | 2014-07-08 |