| NPI | 1164939732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA64935) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 021920) |
| Enumeration Date | 2018-01-04 |
| Last Update Date | 2025-09-18 |