| NPI | 1902176480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 666) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60344927) |
| Enumeration Date | 2011-12-30 |
| Last Update Date | 2020-12-07 |