| NPI | 1629588512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95004825) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 95004825) |
| Enumeration Date | 2017-10-04 |
| Last Update Date | 2019-07-01 |