| NPI | 1770056566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 56456) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NV PA2082) |
| 363AM0700X Physician Assistant, Medical (Licence: NY 025290) | |
| Enumeration Date | 2019-01-04 |
| Last Update Date | 2024-12-18 |