| NPI | 1871226837 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 66771) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: CA PA66771) | |
| Enumeration Date | 2022-07-07 |
| Last Update Date | 2026-06-10 |