| NPI | 1245358449 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 17178) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA19277) |
| Enumeration Date | 2007-03-26 |
| Last Update Date | 2016-09-06 |