| NPI | 1518070036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60600928) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL pa053) |
| Enumeration Date | 2006-08-17 |
| Last Update Date | 2019-10-24 |