| NPI | 1053962597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95012857) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: CA 95012857) |
| 163W00000X Registered Nurse (Licence: CA 633654) | |
| Enumeration Date | 2019-09-26 |
| Last Update Date | 2019-09-26 |