| NPI | 1568801181 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 53357) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA60386057) |
| Enumeration Date | 2013-06-17 |
| Last Update Date | 2017-05-08 |