| NPI | 1679947436 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60894029) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PA.300403) |
| Enumeration Date | 2015-11-17 |
| Last Update Date | 2020-12-09 |