| NPI | 1689217630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA64456) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2019-10-22 |
| Last Update Date | 2024-08-13 |