| NPI | 1689206260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 57466) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 13659) |
| 363AM0700X Physician Assistant, Medical (Licence: CA 57466) | |
| Enumeration Date | 2020-02-11 |
| Last Update Date | 2021-08-20 |