| NPI | 1508331331 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA 60887751) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: WA 60887751) |
| Enumeration Date | 2018-10-08 |
| Last Update Date | 2021-05-04 |