| NPI | 1093469017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA PA64095) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: OK 4748) |
| 363A00000X Physician Assistant (Licence: OK 4748) | |
| Enumeration Date | 2022-02-08 |
| Last Update Date | 2025-03-03 |