| NPI | 1730550112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: CA 95005951) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CA 95053130) |
| Enumeration Date | 2015-10-12 |
| Last Update Date | 2020-05-08 |