| NPI | 1073295556 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 67582) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID 8271583) |
| Enumeration Date | 2023-08-03 |
| Last Update Date | 2026-03-31 |