| NPI | 1003167164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 54186) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9106763) |
| Enumeration Date | 2012-09-28 |
| Last Update Date | 2018-03-17 |