| NPI | 1366716144 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60310422) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA156593) |
| Enumeration Date | 2012-02-27 |
| Last Update Date | 2014-06-03 |