| NPI | 1063763977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA58009) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY P85937) |
| Enumeration Date | 2012-10-02 |
| Last Update Date | 2025-08-07 |