| NPI | 1710174164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA60178573) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA01269) |
| Enumeration Date | 2007-10-01 |
| Last Update Date | 2013-04-11 |