| NPI | 1467635201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA 60285461) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 3678) |
| Enumeration Date | 2007-12-16 |
| Last Update Date | 2021-08-18 |