| NPI | 1356749451 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA PA57736) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 003332) |
| 363AM0700X Physician Assistant, Medical (Licence: CT 003332) | |
| 363AS0400X Physician Assistant, Surgical (Licence: CT 003332) | |
| Enumeration Date | 2014-12-05 |
| Last Update Date | 2021-07-20 |