| NPI | 1891028668 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60109938) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-107376) |
| Enumeration Date | 2009-09-11 |
| Last Update Date | 2022-03-07 |