| NPI | 1790062982 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 57497) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA 9108132) |
| Enumeration Date | 2011-11-15 |
| Last Update Date | 2026-05-27 |