| NPI | 1992172571 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 54708) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 018987) |
| Enumeration Date | 2015-08-30 |
| Last Update Date | 2021-07-28 |