| NPI | 1740226414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1158) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA01055) |
| 363AS0400X Physician Assistant, Surgical (Licence: ID PA-1158) | |
| 363AS0400X Physician Assistant, Surgical (Licence: OR PA01055) | |
| 363AS0400X Physician Assistant, Surgical (Licence: WA PA10004868) | |
| Enumeration Date | 2006-06-21 |
| Last Update Date | 2021-03-25 |