| NPI | 1043980980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95018402) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner Adult Health (Licence: CA 95018402) |
| 363LG0600X Nurse Practitioner Gerontology (Licence: CA 95018402) | |
| Enumeration Date | 2021-09-13 |
| Last Update Date | 2021-11-03 |