| NPI | 1629354683 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60270415) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID GPA-048) |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA60270415) | |
| 363AM0700X Physician Assistant, Medical (Licence: ID PA-936) | |
| Enumeration Date | 2011-10-22 |
| Last Update Date | 2017-02-14 |