| NPI | 1083892236 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AL L6335R) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: AL 00000) |
| 363A00000X Physician Assistant (Licence: CA PA14062) | |
| 363L00000X Nurse Practitioner (Licence: CA 9710) | |
| Enumeration Date | 2008-02-08 |
| Last Update Date | 2024-12-12 |