| NPI | 1952800203 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 57698) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 4082) |
| Enumeration Date | 2018-02-01 |
| Last Update Date | 2020-02-13 |