| NPI | 1356777494 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA57600) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA 57600) |
| 363AM0700X Physician Assistant, Medical (Licence: NY 016964) | |
| Enumeration Date | 2013-09-20 |
| Last Update Date | 2023-05-18 |