| NPI | 1851405989 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA PA15079) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA15079) |
| 363AS0400X Physician Assistant, Surgical (Licence: CA PA15079) | |
| Enumeration Date | 2006-08-18 |
| Last Update Date | 2016-03-15 |