| NPI | 1073274601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA65149) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 4896) |
| 363AM0700X Physician Assistant, Medical (Licence: TN 4896) | |
| Enumeration Date | 2022-01-05 |
| Last Update Date | 2025-03-05 |