| NPI | 1356093322 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA60472) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CA 60472) |
| Enumeration Date | 2022-01-21 |
| Last Update Date | 2022-05-11 |