| NPI | 1104414101 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95016175) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: CA 95016175) |
| Enumeration Date | 2021-01-05 |
| Last Update Date | 2023-09-27 |