| NPI | 1104489343 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 67946) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 95010927) |
| Enumeration Date | 2019-04-14 |
| Last Update Date | 2025-07-15 |