| NPI | 1528170503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR PA01051) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA10003541) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2016-02-03 |