| NPI | 1053165217 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 66779) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 031746) |
| Enumeration Date | 2024-04-15 |
| Last Update Date | 2025-08-15 |