| NPI | 1629732946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner, Pediatrics (Licence: CA 95032634) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CA RN95132765) |
| Enumeration Date | 2021-10-22 |
| Last Update Date | 2025-03-28 |