| NPI | 1184971400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 61081) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05860) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-05860) | |
| Enumeration Date | 2012-08-06 |
| Last Update Date | 2022-07-12 |