| NPI | 1407958911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: OR PA184071) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WA PA10002489) |
| 363AS0400X Physician Assistant Surgical (Licence: MT 210) | |
| Enumeration Date | 2006-09-04 |
| Last Update Date | 2018-05-23 |