| NPI | 1720315336 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: CA 19738) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA20650) |
| Enumeration Date | 2009-11-03 |
| Last Update Date | 2012-06-11 |