| NPI | 1285979815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 22741) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 13437) |
| Enumeration Date | 2012-12-08 |
| Last Update Date | 2015-09-10 |