| NPI | 1861478687 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA PA16383) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-01534) |
| Enumeration Date | 2005-12-22 |
| Last Update Date | 2011-08-17 |