| NPI | 1790232122 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA59440) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA185271) |
| Enumeration Date | 2016-09-01 |
| Last Update Date | 2022-06-07 |