| NPI | 1669725644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 61454) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110005055) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2012-10-16 |
| Last Update Date | 2022-10-12 |