| NPI | 1821436734 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 61449) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 59445) |
| 363A00000X Physician Assistant (Licence: IA 002401) | |
| Enumeration Date | 2013-06-13 |
| Last Update Date | 2023-01-23 |