| NPI | 1457914178 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 59560) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 7420) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9112389) | |
| Enumeration Date | 2019-04-18 |
| Last Update Date | 2022-06-23 |