| NPI | 1801888367 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA00255) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA10003194) |
| Enumeration Date | 2005-08-19 |
| Last Update Date | 2011-04-18 |