| NPI | 1720020704 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA15834) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 103999) |
| Enumeration Date | 2006-06-12 |
| Last Update Date | 2012-03-08 |