| NPI | 1003668138 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MD R270779) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CA 95018766) |
| Enumeration Date | 2024-04-02 |
| Last Update Date | 2025-08-11 |