| NPI | 1366111601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA60276) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 8772001206) |
| Enumeration Date | 2021-09-09 |
| Last Update Date | 2025-09-10 |