| NPI | 1346232311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA 10547) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA PA 10547) |
| 363AS0400X Physician Assistant, Surgical (Licence: CA PA10547) | |
| Enumeration Date | 2005-08-16 |
| Last Update Date | 2011-04-05 |