NPI | 1205461589 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 66401) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: DC PA031822) |
Enumeration Date | 2020-03-07 |
Last Update Date | 2025-09-08 |