| NPI | 1861842106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA61703) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2016-06-17 |
| Last Update Date | 2023-07-11 |