NPI | 1376054650 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA 55036) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 55036) |
363A00000X Physician Assistant (Licence: WI 72211) | |
Enumeration Date | 2017-10-13 |
Last Update Date | 2024-03-29 |