| NPI | 1760072557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: ID 77227) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 95015235) |
| Enumeration Date | 2021-01-25 |
| Last Update Date | 2026-06-16 |