| NPI | 1053394809 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 10203) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 241526) |
| Enumeration Date | 2005-11-25 |
| Last Update Date | 2007-07-09 |