| NPI | 1730904699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: CA 95030904) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CA 95171857) |
| 363L00000X Nurse Practitioner (Licence: CA 95030904) | |
| Enumeration Date | 2024-11-16 |
| Last Update Date | 2026-03-05 |