| NPI | 1376209478 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA61186280) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA.PA.61186280) |
| Enumeration Date | 2021-11-12 |
| Last Update Date | 2022-02-03 |