| NPI | 1417293580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA22729) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 016391) |
| Enumeration Date | 2012-12-18 |
| Last Update Date | 2015-06-04 |