| NPI | 1891841375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 3976) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA#12407) |
| Enumeration Date | 2007-01-26 |
| Last Update Date | 2011-08-10 |