| NPI | 1760436968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA10004193) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA PA19017) |
| Enumeration Date | 2006-05-20 |
| Last Update Date | 2012-12-17 |