| NPI | 1164806329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55746) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 11807) |
| Enumeration Date | 2015-07-16 |
| Last Update Date | 2023-04-28 |