| NPI | 1437591674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 52105) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IL 085.004679) |
| Enumeration Date | 2013-07-29 |
| Last Update Date | 2020-07-01 |