| NPI | 1154516490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA21014) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002612) |
| Enumeration Date | 2007-09-10 |
| Last Update Date | 2018-07-05 |