| NPI | 1902016611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: CA RN376101) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: CA PA12304) |
| Enumeration Date | 2007-05-23 |
| Last Update Date | 2015-05-07 |