| NPI | 1538723937 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61135685) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 23.004437) |
| 363AS0400X Physician Assistant Surgical (Licence: CT 4437) | |
| Enumeration Date | 2019-05-01 |
| Last Update Date | 2021-04-19 |