| NPI | 1811976251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61168147) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 6030) |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 6030) | |
| 363A00000X Physician Assistant (Licence: AZ 6030) | |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA61168147) | |
| Enumeration Date | 2006-01-13 |
| Last Update Date | 2022-11-16 |