| NPI | 1710036587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA10004262) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11053) |
| Enumeration Date | 2007-01-09 |
| Last Update Date | 2016-10-24 |