NPI | 1366509507 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ID PA-904) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA60143655) |
Enumeration Date | 2007-01-03 |
Last Update Date | 2022-03-14 |