| NPI | 1902803844 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA10004994) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 001531) |
| Enumeration Date | 2005-07-07 |
| Last Update Date | 2014-09-04 |