| NPI | 1649766114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA58355) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: RI PA01031) |
| Enumeration Date | 2018-07-07 |
| Last Update Date | 2020-09-25 |