| NPI | 1649473950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60298891) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9102810) |
| 363A00000X Physician Assistant (Licence: FL PA9102812) | |
| Enumeration Date | 2007-06-06 |
| Last Update Date | 2015-01-05 |