| NPI | 1700114246 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA 52390) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA 60122767) |
| Enumeration Date | 2009-11-20 |
| Last Update Date | 2016-10-11 |