| NPI | 1760595599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA pa10004192) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA382) |
| 363AM0700X Physician Assistant, Medical (Licence: WA pa10004192) | |
| Enumeration Date | 2006-08-16 |
| Last Update Date | 2022-10-13 |