| NPI | 1588658124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: WA PA10004277) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CA PA16431) |
| Enumeration Date | 2005-09-09 |
| Last Update Date | 2008-03-11 |