| NPI | 1639604978 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95016497) |
| Additional Taxonomies | 363LA2100X Nurse Practitioner, Acute Care (Licence: KS 53-77629) |
| Enumeration Date | 2017-04-24 |
| Last Update Date | 2025-12-01 |