| NPI | 1316584907 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA NP95012512) |
| Additional Taxonomies | 261QM1300X Clinic/Center, Multi-Specialty |
| Enumeration Date | 2019-12-03 |
| Last Update Date | 2021-12-21 |