| NPI | 1568973576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA OA60803041) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA.0777859) |
| Enumeration Date | 2017-10-17 |
| Last Update Date | 2020-12-07 |