| NPI | 1518064187 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60289680) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX 1051150) |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA06123) | |
| Enumeration Date | 2006-09-17 |
| Last Update Date | 2015-02-23 |