| NPI | 1093209843 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55561) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA55561) |
| Enumeration Date | 2018-06-15 |
| Last Update Date | 2021-06-09 |