| NPI | 1649726852 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: WA OA60743170) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| Enumeration Date | 2016-08-28 |
| Last Update Date | 2019-12-13 |