| NPI | 1639471667 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA BG60555472) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2010-11-24 |
| Last Update Date | 2015-10-14 |