| NPI | 1679896674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA20359) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MO 2025037851) |
| Enumeration Date | 2010-03-04 |
| Last Update Date | 2025-11-12 |