| NPI | 1679082796 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55842) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 021341) |
| Enumeration Date | 2017-09-20 |
| Last Update Date | 2018-09-10 |