| NPI | 1750710919 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA PA54390) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60489241) |
| 363AM0700X Physician Assistant, Medical (Licence: UT 8818001-1206) | |
| Enumeration Date | 2013-11-07 |
| Last Update Date | 2025-03-18 |