| NPI | 1457644973 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 4847) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA 21649) |
| Enumeration Date | 2011-05-17 |
| Last Update Date | 2025-01-08 |