| NPI | 1164450003 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA 14825) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CA ,374060) |
| Enumeration Date | 2006-06-29 |
| Last Update Date | 2007-07-08 |