| NPI | 1336543008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60509828) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60509828) |
| Enumeration Date | 2014-10-09 |
| Last Update Date | 2019-06-10 |