| NPI | 1376920918 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA 60516081) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA169881) |
| Enumeration Date | 2015-05-04 |
| Last Update Date | 2020-04-29 |