| NPI | 1780091306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA PA60654839) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 017728) |
| Enumeration Date | 2014-07-15 |
| Last Update Date | 2019-11-18 |