| NPI | 1912314097 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 61255) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MN 11679) |
| Enumeration Date | 2014-07-21 |
| Last Update Date | 2022-10-31 |