| NPI | 1598167827 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9108396) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 51770) |
| Enumeration Date | 2014-09-17 |
| Last Update Date | 2022-08-16 |