| NPI | 1043641822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07561) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA51287) |
| Enumeration Date | 2013-12-04 |
| Last Update Date | 2020-03-24 |