| NPI | 1801873500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60602810) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: 1070456) |
| Enumeration Date | 2005-12-23 |
| Last Update Date | 2021-05-11 |