| NPI | 1760884530 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: CA 95001306) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CA 95001306) |
| Enumeration Date | 2014-09-23 |
| Last Update Date | 2018-10-25 |