| NPI | 1881970200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60991959) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: SC 6554) |
| 363A00000X Physician Assistant (Licence: LA PA.200822) | |
| 363AS0400X Physician Assistant Surgical (Licence: AL PA987) | |
| Enumeration Date | 2011-10-31 |
| Last Update Date | 2020-01-14 |