| NPI | 1215058037 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 4777) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA PA 17169) |
| Enumeration Date | 2007-04-02 |
| Last Update Date | 2023-03-23 |