| NPI | 1760663728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: WA PA60009293) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-912) |
| Enumeration Date | 2007-11-19 |
| Last Update Date | 2021-05-18 |