| NPI | 1730444175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60652694) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA PA4432) |
| Enumeration Date | 2012-07-11 |
| Last Update Date | 2023-08-30 |