| NPI | 1366750804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60186366) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-112897) |
| Enumeration Date | 2010-09-17 |
| Last Update Date | 2023-11-02 |