| NPI | 1104804905 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 62800) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA911833) |
| 363A00000X Physician Assistant (Licence: DE C50000259) | |
| Enumeration Date | 2006-01-03 |
| Last Update Date | 2024-02-15 |