| NPI | 1508901232 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CA PA11430) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: CA PA11430) |
| Enumeration Date | 2007-02-20 |
| Last Update Date | 2014-07-03 |