| NPI | 1417511437 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95011325) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CA 95011325) |
| Enumeration Date | 2019-04-25 |
| Last Update Date | 2021-10-22 |