| 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 |