| NPI | 1568765576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 54415) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5035) |
| 363A00000X Physician Assistant (Licence: HI AMD-511) | |
| Enumeration Date | 2010-12-13 |
| Last Update Date | 2019-02-11 |