| NPI | 1366711293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-04610) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA21284) |
| Enumeration Date | 2011-12-21 |
| Last Update Date | 2025-01-24 |