| NPI | 1245204361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA PA21573) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA497) |
| Enumeration Date | 2006-02-15 |
| Last Update Date | 2013-06-12 |