| NPI | 1790210573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA68303) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA6092772) |
| Enumeration Date | 2017-04-28 |
| Last Update Date | 2026-06-19 |