| NPI | 1811191687 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA13593) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV 999) |
| Enumeration Date | 2007-06-13 |
| Last Update Date | 2012-09-05 |