| NPI | 1780165514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 65153) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0008522) |
| Enumeration Date | 2018-08-29 |
| Last Update Date | 2025-02-03 |