| NPI | 1235549932 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY pa799) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60463399) |
| Enumeration Date | 2014-05-02 |
| Last Update Date | 2020-09-21 |