| NPI | 1972572303 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60303546) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: WY 267) |
| Enumeration Date | 2006-03-17 |
| Last Update Date | 2021-05-25 |