| NPI | 1437748191 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 62817) | 
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA2442) | 
| Enumeration Date | 2021-01-15 | 
| Last Update Date | 2025-09-29 |