| NPI | 1649345281 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA PA13839) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA13839) |
| 363L00000X Nurse Practitioner (Licence: CA 6393) | |
| Enumeration Date | 2006-11-21 |
| Last Update Date | 2021-04-06 |