| NPI | 1962776088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60310447) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60310447) |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 014858) | |
| Enumeration Date | 2012-03-07 |
| Last Update Date | 2020-12-09 |