| NPI | 1457329542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: AK 139988) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10003794) |
| 363AM0700X Physician Assistant, Medical (Licence: AK 139988) | |
| Enumeration Date | 2006-03-14 |
| Last Update Date | 2018-12-31 |