| NPI | 1285010322 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 53159) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 081905) |
| Enumeration Date | 2015-07-30 |
| Last Update Date | 2021-02-11 |