| NPI | 1609222017 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2133) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CA PA53741) |
| Enumeration Date | 2016-05-05 |
| Last Update Date | 2024-04-25 |