| NPI | 1154472256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 2005) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 14822) |
| 363AM0700X Physician Assistant, Medical (Licence: ID 2005) | |
| Enumeration Date | 2007-01-15 |
| Last Update Date | 2023-07-10 |