| NPI | 1336156496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-176) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: WA PA10003546) | |
| Enumeration Date | 2006-08-02 |
| Last Update Date | 2016-07-14 |