| NPI | 1053563965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 4601) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA20030) |
| Enumeration Date | 2008-10-22 |
| Last Update Date | 2020-09-15 |