| NPI | 1679597868 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 18751) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 245) |
| Enumeration Date | 2006-07-27 |
| Last Update Date | 2021-10-11 |