| NPI | 1760565691 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA12089) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA RN308745) |
| Enumeration Date | 2006-10-23 |
| Last Update Date | 2007-07-08 |