| NPI | 1790704815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60064004) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ND PAC0119) |
| 363A00000X Physician Assistant (Licence: WA PA60064004) | |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA60064004) | |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2016-02-22 |