| NPI | 1679584130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA10004846) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.000662) |
| Enumeration Date | 2006-08-10 |
| Last Update Date | 2013-05-21 |