| NPI | 1578171260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 61945) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-10323) |
| Enumeration Date | 2020-07-19 |
| Last Update Date | 2025-01-28 |