| NPI | 1720198674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 11333) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 481865) |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2008-03-17 |