| NPI | 1679019863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 59620) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA11148) |
| 363A00000X Physician Assistant (Licence: IN 10002663A) | |
| Enumeration Date | 2017-01-11 |
| Last Update Date | 2022-03-03 |