| NPI | 1396290532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60846865) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 9893685-1206) |
| Enumeration Date | 2016-08-17 |
| Last Update Date | 2020-04-28 |