| NPI | 1740604495 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 61054) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA1595) |
| Enumeration Date | 2014-02-14 |
| Last Update Date | 2025-11-03 |