| NPI | 1588907505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61024630) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NM PA2016-0014) |
| Enumeration Date | 2013-03-27 |
| Last Update Date | 2020-03-10 |