| NPI | 1184189839 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 56475) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-1826) |
| Enumeration Date | 2019-02-06 |
| Last Update Date | 2020-01-10 |