| NPI | 1174867410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA22292) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-2794) |
| 363AM0700X Physician Assistant Medical (Licence: CA PA22292) | |
| Enumeration Date | 2012-11-26 |
| Last Update Date | 2024-05-16 |