| NPI | 1447586144 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 18833) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 53170) |
| 363AS0400X Physician Assistant, Surgical (Licence: CA 53170) | |
| 363AS0400X Physician Assistant, Surgical (Licence: LA 200447) | |
| 363L00000X Nurse Practitioner (Licence: LA AP06311) | |
| Enumeration Date | 2009-10-30 |
| Last Update Date | 2023-08-30 |