| NPI | 1760448294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA10004944) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA557) |
| Enumeration Date | 2006-04-24 |
| Last Update Date | 2013-05-31 |