| NPI | 1619241551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60416858) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OR PA164425) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-02-23 |
| Last Update Date | 2017-06-09 |