| NPI | 1295130516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60514742) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0004564) |
| Enumeration Date | 2014-10-29 |
| Last Update Date | 2016-07-06 |