| NPI | 1528501475 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: ID PA-1454) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WA PA.PA.60708796) |
| Enumeration Date | 2016-11-27 |
| Last Update Date | 2019-01-15 |