| NPI | 1184120784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95011740) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL RN9306101) |
| Enumeration Date | 2018-04-03 |
| Last Update Date | 2019-07-03 |