| NPI | 1518454396 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA 57007) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 7061) |
| Enumeration Date | 2018-04-17 |
| Last Update Date | 2025-06-13 |