| NPI | 1891506804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AZ 11023) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 65547) |
| 363A00000X Physician Assistant (Licence: AZ 11023) | |
| Enumeration Date | 2025-01-17 |
| Last Update Date | 2025-06-25 |