| NPI | 1891164471 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA54184) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 019114) |
| 363AS0400X Physician Assistant, Surgical (Licence: CA PA54184) | |
| Enumeration Date | 2015-09-24 |
| Last Update Date | 2026-09-10 |