| NPI | 1982084141 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA57468) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: GA 10568) | |
| Enumeration Date | 2015-06-03 |
| Last Update Date | 2021-09-30 |