| NPI | 1104153899 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 7956) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: AZ 7956) |
| 363A00000X Physician Assistant | |
| 363AM0700X Physician Assistant Medical (Licence: CA PA20635) | |
| Enumeration Date | 2009-11-17 |
| Last Update Date | 2022-12-22 |