| NPI | 1740607167 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95000320) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: CA 95000320) |
| 363LG0600X Nurse Practitioner, Gerontology (Licence: CA 95000320) | |
| Enumeration Date | 2014-03-24 |
| Last Update Date | 2015-09-29 |