| NPI | 1417310657 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 6703) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 53246) |
| Enumeration Date | 2016-04-04 |
| Last Update Date | 2019-11-07 |