| NPI | 1023006715 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 1025865) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 6740) |
| 363LF0000X Nurse Practitioner, Family (Licence: CA 445691) | |
| Enumeration Date | 2005-10-07 |
| Last Update Date | 2023-09-13 |