| NPI | 1114782398 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95017580) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 95017580) |
| Enumeration Date | 2024-02-16 |
| Last Update Date | 2025-07-23 |