| NPI | 1508222084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 54923) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN 2936) |
| Enumeration Date | 2016-01-13 |
| Last Update Date | 2020-02-20 |