| NPI | 1780985457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA 54382) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA1439) |
| 363AM0700X Physician Assistant, Medical (Licence: TX PA13827) | |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2010-11-10 |
| Last Update Date | 2021-09-02 |