| NPI | 1164655569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 17184) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: CA 17184) |
| 363LF0000X Nurse Practitioner, Family (Licence: CA 17184) | |
| Enumeration Date | 2009-09-01 |
| Last Update Date | 2025-12-24 |