| NPI | 1104219203 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA NP95015615) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: HI 2095) |
| 163W00000X Registered Nurse (Licence: HI 82632) | |
| Enumeration Date | 2015-03-13 |
| Last Update Date | 2020-12-17 |