| NPI | 1194382077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 62204) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 9503) |
| 363A00000X Physician Assistant (Licence: MI 5601009199) | |
| Enumeration Date | 2019-05-25 |
| Last Update Date | 2024-06-28 |