| NPI | 1235612177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NM 55911) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CA 95009939) |
| Enumeration Date | 2018-09-06 |
| Last Update Date | 2019-07-03 |