| NPI | 1326125485 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60099484) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-1221) |
| 363AM0700X Physician Assistant, Medical (Licence: WY 361) | |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA60099484) | |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2024-04-01 |