| NPI | 1245622646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 7075) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 57093) |
| Enumeration Date | 2015-02-23 |
| Last Update Date | 2022-06-08 |