| NPI | 1972823094 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA60582305) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-02344) |
| Enumeration Date | 2010-06-11 |
| Last Update Date | 2019-06-25 |