| NPI | 1073941167 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA64798) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5575) |
| Enumeration Date | 2013-10-29 |
| Last Update Date | 2025-02-13 |