| NPI | 1346293313 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-362) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA362) |
| 363A00000X Physician Assistant (Licence: WA PA60064009) | |
| 363AS0400X Physician Assistant Surgical (Licence: ID PA-362) | |
| Enumeration Date | 2006-05-18 |
| Last Update Date | 2024-09-13 |