| NPI | 1336491588 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60319271) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2012-0050) |
| Enumeration Date | 2012-10-12 |
| Last Update Date | 2021-07-07 |