| NPI | 1619197449 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA.PA.60173835) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WA a160047664) |
| Enumeration Date | 2007-04-26 |
| Last Update Date | 2011-10-21 |