| NPI | 1861834798 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001005014) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA 60404645) |
| Enumeration Date | 2013-07-19 |
| Last Update Date | 2016-03-14 |