| NPI | 1417998055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA10004056) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA10004056) |
| 363AS0400X Physician Assistant, Surgical (Licence: WA PA10004056) | |
| Enumeration Date | 2006-06-08 |
| Last Update Date | 2025-08-06 |