| NPI | 1124020706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 17096) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CA 14495) |
| Enumeration Date | 2005-08-12 |
| Last Update Date | 2015-05-19 |