| NPI | 1750130951 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA65037) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9119159) |
| Enumeration Date | 2024-05-18 |
| Last Update Date | 2024-10-25 |