| NPI | 1013568088 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA 59492) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 7657) |
| Enumeration Date | 2019-09-21 |
| Last Update Date | 2021-06-17 |