| NPI | 1700833217 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OR 169107) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 630) |
| 363AM0700X Physician Assistant, Medical (Licence: HI 258) | |
| 363AM0700X Physician Assistant, Medical (Licence: WA 10003812) | |
| Enumeration Date | 2006-05-28 |
| Last Update Date | 2021-12-03 |