| NPI | 1730778978 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA 59223) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA59223) |
| 363AM0700X Physician Assistant, Medical | |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2021-01-12 |
| Last Update Date | 2025-01-08 |