| NPI | 1790465375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 67798) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 9748) |
| Enumeration Date | 2023-07-19 |
| Last Update Date | 2026-04-28 |