| NPI | 1558611822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA61179237) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OR PA176068) |
| 363AM0700X Physician Assistant, Medical (Licence: ID PA1449) | |
| Enumeration Date | 2012-09-14 |
| Last Update Date | 2022-05-11 |