| NPI | 1093317760 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 62427) |
| 363A00000X Physician Assistant (Licence: CA PA62427) | |
| Enumeration Date | 2020-11-09 |
| Last Update Date | 2024-08-17 |