| NPI | 1417081019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA 60416598) |
| Additional Taxonomies | 174400000X Specialist (Licence: WA 060402482) |
| Enumeration Date | 2007-03-15 |
| Last Update Date | 2013-11-05 |