| NPI | 1366833923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1963) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 52315) |
| Enumeration Date | 2015-02-17 |
| Last Update Date | 2025-05-29 |