| NPI | 1003468331 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA PA66051) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA66051) |
| Enumeration Date | 2019-07-16 |
| Last Update Date | 2026-01-31 |