| NPI | 1992743215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA61078913) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OR PA01128) |
| 363AS0400X Physician Assistant, Surgical (Licence: ID PA-6052) | |
| Enumeration Date | 2006-06-02 |
| Last Update Date | 2022-03-24 |