| NPI | 1871117481 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA61077208) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical |
| Enumeration Date | 2020-05-31 |
| Last Update Date | 2021-11-11 |