| NPI | 1124664636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 58617) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 5126) |
| Enumeration Date | 2019-11-19 |
| Last Update Date | 2024-09-20 |