| NPI | 1659689768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60572496) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR 153066) |
| Enumeration Date | 2010-09-23 |
| Last Update Date | 2015-09-18 |