| NPI | 1679899975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA180199) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA 60201528) |
| 363A00000X Physician Assistant (Licence: CT 003052) | |
| 363AM0700X Physician Assistant, Medical (Licence: NC 001002276) | |
| Enumeration Date | 2010-04-12 |
| Last Update Date | 2022-07-21 |