| NPI | 1861113532 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA 68876) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0008365) |
| Enumeration Date | 2022-09-09 |
| Last Update Date | 2026-08-18 |