| NPI | 1790304665 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA 59482) |
| Enumeration Date | 2020-04-10 |
| Last Update Date | 2024-10-25 |