| NPI | 1376845206 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60197218) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA60197218) |
| 363AM0700X Physician Assistant, Medical (Licence: CA 53707) | |
| Enumeration Date | 2010-11-29 |
| Last Update Date | 2019-11-29 |