| NPI | 1134259054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 1065185) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: CA 15753) |
| Enumeration Date | 2007-03-07 |
| Last Update Date | 2007-07-08 |