| NPI | 1346376555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 3918) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 1004104) |
| Enumeration Date | 2007-02-24 |
| Last Update Date | 2014-04-11 |