| NPI | 1770523805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA01228) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10000432) |
| Enumeration Date | 2006-06-07 |
| Last Update Date | 2012-02-09 |