| NPI | 1891780524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60997082) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-558) |
| Enumeration Date | 2005-09-19 |
| Last Update Date | 2019-12-09 |