| NPI | 1487345823 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NV PA3190) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: CA PA65106) | |
| Enumeration Date | 2023-05-17 |
| Last Update Date | 2025-06-24 |