| NPI | 1114649464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA61879) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: CA 61879) | |
| Enumeration Date | 2022-09-14 |
| Last Update Date | 2022-10-27 |