| NPI | 1578562815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA10003341) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: ID PA-457) |
| Enumeration Date | 2005-07-19 |
| Last Update Date | 2011-12-19 |