| NPI | 1679653745 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA10005254) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OR PA01153) |
| Enumeration Date | 2006-10-16 |
| Last Update Date | 2012-02-23 |