| NPI | 1477021020 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA56759) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-1650) |
| Enumeration Date | 2018-11-12 |
| Last Update Date | 2020-11-04 |