| NPI | 1104371251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 58420) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA5833) |
| Enumeration Date | 2016-08-18 |
| Last Update Date | 2021-06-09 |