| NPI | 1356713028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA55517) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 019319) |
| Enumeration Date | 2015-10-21 |
| Last Update Date | 2019-09-09 |