| NPI | 1013365923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 53192) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CA 53192) |
| Enumeration Date | 2016-06-01 |
| Last Update Date | 2016-06-01 |