| NPI | 1225053028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 51804) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA01125) |
| 363A00000X Physician Assistant (Licence: AZ 4637) | |
| Enumeration Date | 2006-07-13 |
| Last Update Date | 2015-04-07 |