| NPI | 1679319289 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95030825) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CA 95030825) |
| Enumeration Date | 2024-07-02 |
| Last Update Date | 2025-11-24 |