| NPI | 1598141921 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08047) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 52639) |
| Enumeration Date | 2015-08-07 |
| Last Update Date | 2021-09-16 |