| NPI | 1598167074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 9035) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60600014) |
| Enumeration Date | 2014-09-16 |
| Last Update Date | 2022-06-30 |