| NPI | 1124601422 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95017256) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 95017256) |
| Enumeration Date | 2021-05-04 |
| Last Update Date | 2026-02-03 |