| NPI | 1982121125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WA OA60920124) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ID PA-1845) |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA60920248) | |
| Enumeration Date | 2017-08-28 |
| Last Update Date | 2020-07-14 |