| NPI | 1174936454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 22668) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 22668) |
| Enumeration Date | 2014-06-04 |
| Last Update Date | 2018-06-06 |