| NPI | 1457864597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA55619) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-11-12 |
| Last Update Date | 2019-07-22 |