| NPI | 1669063384 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 53451) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CA 95016395) |
| Enumeration Date | 2021-01-27 |
| Last Update Date | 2026-05-12 |