| NPI | 1801564448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 14172614-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA61843) |
| Enumeration Date | 2021-08-30 |
| Last Update Date | 2025-07-28 |