| NPI | 1104393651 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: CA 95018639) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11042755) |
| 363LF0000X Nurse Practitioner, Family (Licence: TN 24976) | |
| Enumeration Date | 2018-11-01 |
| Last Update Date | 2026-04-16 |