| NPI | 1932619509 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55149) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 13084735-1206) |
| Enumeration Date | 2017-10-09 |
| Last Update Date | 2024-12-14 |