| NPI | 1518442649 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA PA67143) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA066384) |
| 363AM0700X Physician Assistant, Medical (Licence: TX PA12285) | |
| Enumeration Date | 2018-09-25 |
| Last Update Date | 2025-10-09 |