| NPI | 1134522394 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 63909) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA 63909) |
| 363A00000X Physician Assistant (Licence: MI 5601007201) | |
| Enumeration Date | 2014-10-02 |
| Last Update Date | 2025-12-18 |