| NPI | 1700336120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: WA PA60700306) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA 60700306) |
| Enumeration Date | 2016-10-10 |
| Last Update Date | 2016-11-18 |