| NPI | 1700855574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-684) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: ID PA-684) |
| 363A00000X Physician Assistant (Licence: WA PA10004260) | |
| Enumeration Date | 2006-03-15 |
| Last Update Date | 2015-12-07 |