| NPI | 1891234340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55767) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0006392) |
| 363A00000X Physician Assistant (Licence: FL 9110188) | |
| Enumeration Date | 2017-02-16 |
| Last Update Date | 2025-09-30 |