| NPI | 1245669340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PAG-028) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 51293) |
| Enumeration Date | 2013-11-08 |
| Last Update Date | 2022-03-03 |