| NPI | 1477634616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AK 1221) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR 00948) |
| 363A00000X Physician Assistant (Licence: WA pa10005159) | |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2016-12-19 |