| NPI | 1245192103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95038149) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CA 95108688) |
| Enumeration Date | 2025-12-01 |
| Last Update Date | 2026-01-26 |