| NPI | 1508332305 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA PA56630) |
| Additional Taxonomies | 207QA0505X Family Medicine, Adult Medicine (Licence: CA PA56630) |
| Enumeration Date | 2018-10-18 |
| Last Update Date | 2025-01-21 |