| NPI | 1366755993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 005811) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 54202) |
| Enumeration Date | 2010-07-25 |
| Last Update Date | 2024-09-20 |