| NPI | 1629668256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95026453) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CA 95224464) |
| Enumeration Date | 2021-01-18 |
| Last Update Date | 2026-04-14 |