| NPI | 1548892110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2484) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA57810) |
| 363AM0700X Physician Assistant, Medical (Licence: CA PA57810) | |
| Enumeration Date | 2020-02-11 |
| Last Update Date | 2024-08-08 |