| NPI | 1174015192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA55642) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care |
| Enumeration Date | 2018-06-05 |
| Last Update Date | 2018-10-15 |