| NPI | 1992115950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 58476) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ME PA1890) |
| 363AM0700X Physician Assistant, Medical (Licence: WA PA60450043) | |
| Enumeration Date | 2014-04-30 |
| Last Update Date | 2025-07-03 |