| NPI | 1386063980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1176) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 51458) |
| Enumeration Date | 2014-04-10 |
| Last Update Date | 2023-03-10 |