| NPI | 1154831915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 56965) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-1564) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2017-10-06 |
| Last Update Date | 2024-09-20 |