| NPI | 1376716084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA 58405) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: GA 5325) |
| Enumeration Date | 2008-04-02 |
| Last Update Date | 2020-10-19 |