| NPI | 1114639911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95026874) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CA 95175469) |
| Enumeration Date | 2022-12-23 |
| Last Update Date | 2025-12-02 |