| NPI | 1184980674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CA PA22175) |
| Enumeration Date | 2012-04-09 |
| Last Update Date | 2025-05-18 |