| NPI | 1104014562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA PA19208) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA19208) |
| Enumeration Date | 2007-10-11 |
| Last Update Date | 2022-01-03 |