| NPI | 1609110105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: CA 760402) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 21182) |
| Enumeration Date | 2012-11-21 |
| Last Update Date | 2019-04-05 |