| NPI | 1033557301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA 1110524) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA23052) |
| Enumeration Date | 2013-06-10 |
| Last Update Date | 2025-08-01 |