| NPI | 1699024505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60310476) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA60310476) |
| 363AS0400X Physician Assistant, Surgical (Licence: WA PA60310476) | |
| Enumeration Date | 2012-09-06 |
| Last Update Date | 2024-09-23 |