| NPI | 1669760120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA60470619) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5601006041) |
| 363AM0700X Physician Assistant, Medical (Licence: OR MC2783290) | |
| 363AM0700X Physician Assistant, Medical (Licence: WA MC3397886) | |
| Enumeration Date | 2011-07-19 |
| Last Update Date | 2023-01-13 |