| NPI | 1619640141 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95017112) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CA 95078590) |
| Enumeration Date | 2021-07-29 |
| Last Update Date | 2026-08-17 |