| NPI | 1790080182 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA20054) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CA 20641) |
| Enumeration Date | 2011-01-17 |
| Last Update Date | 2015-11-19 |