| NPI | 1073275467 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 59734) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA 59734) |
| Enumeration Date | 2021-10-12 |
| Last Update Date | 2022-11-29 |