| NPI | 1356486021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 19058) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: CA 17075) |
| Enumeration Date | 2007-02-21 |
| Last Update Date | 2007-07-08 |