| NPI | 1538604822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55959) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 020488) |
| Enumeration Date | 2016-12-22 |
| Last Update Date | 2025-10-10 |