| NPI | 1891210324 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 60615) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL pa9110850) |
| Enumeration Date | 2017-08-05 |
| Last Update Date | 2022-09-20 |