| NPI | 1174712624 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA20585) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002657) |
| Enumeration Date | 2007-10-22 |
| Last Update Date | 2015-06-15 |