| NPI | 1730676412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11029427) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 95021148) |
| Enumeration Date | 2018-04-17 |
| Last Update Date | 2026-04-20 |