| NPI | 1275868572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: WA PA60115570) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WA PA60115570) |
| 363A00000X Physician Assistant (Licence: WA PA60115570) | |
| Enumeration Date | 2009-10-05 |
| Last Update Date | 2017-01-23 |