| NPI | 1285677625 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: WA 60120197) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: WA 60120197) |
| 363AM0700X Physician Assistant Medical (Licence: AZ 1009) | |
| 363AM0700X Physician Assistant Medical (Licence: CA 10374) | |
| 363AS0400X Physician Assistant Surgical (Licence: AZ 1009) | |
| 363AS0400X Physician Assistant Surgical (Licence: CA 10374) | |
| Enumeration Date | 2006-06-14 |
| Last Update Date | 2013-02-12 |