| NPI | 1285911412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 1250) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA21995) |
| Enumeration Date | 2011-11-16 |
| Last Update Date | 2021-01-25 |