| NPI | 1891071080 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 51720) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0007584) |
| 363A00000X Physician Assistant (Licence: VA 0110007462) | |
| 363A00000X Physician Assistant (Licence: 1098380) | |
| Enumeration Date | 2011-11-01 |
| Last Update Date | 2023-10-18 |