| NPI | 1982765616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WA PA0001419) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA10001419) |
| Enumeration Date | 2006-12-13 |
| Last Update Date | 2019-12-05 |