| NPI | 1679714620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 52742) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CA 20203) |
| Enumeration Date | 2009-03-20 |
| Last Update Date | 2022-12-02 |