| NPI | 1417440603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: CA PA5670) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| Enumeration Date | 2018-06-12 |
| Last Update Date | 2021-03-15 |