| NPI | 1780679068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA446) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA10004517) |
| Enumeration Date | 2005-09-13 |
| Last Update Date | 2015-08-18 |