| NPI | 1942856232 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-10269) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 59677) |
| Enumeration Date | 2019-08-13 |
| Last Update Date | 2025-01-24 |