| NPI | 1821685942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 8362) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: CA 59331) | |
| Enumeration Date | 2020-12-22 |
| Last Update Date | 2022-08-16 |