| NPI | 1639450885 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA22271) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 8082580-1206) |
| 363A00000X Physician Assistant (Licence: UT 8082580-8906) | |
| Enumeration Date | 2011-09-01 |
| Last Update Date | 2013-07-31 |