| NPI | 1053579821 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95033213) |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Enumeration Date | 2008-05-29 |
| Last Update Date | 2024-12-30 |