| NPI | 1114128006 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55237) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CA NP10568) |
| Enumeration Date | 2007-05-30 |
| Last Update Date | 2018-08-13 |