| NPI | 1265450092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA .60236031) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IA 001656) |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2012-09-25 |