| NPI | 1922162510 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60859694) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA06828) |
| 363AM0700X Physician Assistant, Medical (Licence: AK 853) | |
| Enumeration Date | 2006-12-20 |
| Last Update Date | 2023-02-15 |