| NPI | 1831756717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA62203) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 9418) |
| 363AM0700X Physician Assistant, Medical (Licence: MI 5601009198) | |
| Enumeration Date | 2019-05-25 |
| Last Update Date | 2024-07-02 |