| NPI | 1417026097 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA10004850) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 31003) |
| 363A00000X Physician Assistant (Licence: TX PA05405) | |
| Enumeration Date | 2006-11-07 |
| Last Update Date | 2018-04-05 |