| NPI | 1215130802 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV PA925) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA18021) |
| Enumeration Date | 2007-06-09 |
| Last Update Date | 2018-07-17 |