| NPI | 1962894220 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 54224) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 018481) |
| Enumeration Date | 2015-02-24 |
| Last Update Date | 2026-08-20 |