| NPI | 1609172758 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55756) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5953) |
| Enumeration Date | 2011-02-08 |
| Last Update Date | 2018-11-29 |