| NPI | 1902206071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 7033) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60507644) |
| Enumeration Date | 2014-08-26 |
| Last Update Date | 2020-02-05 |