| NPI | 1861953499 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 63568) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 4551) |
| Enumeration Date | 2019-03-27 |
| Last Update Date | 2024-04-11 |