| 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 |