| NPI | 1669256673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA66727) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0008393) |
| Enumeration Date | 2023-08-21 |
| Last Update Date | 2025-08-18 |