| NPI | 1770991119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: CA 95000899) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CA 95000899) |
| Enumeration Date | 2014-07-29 |
| Last Update Date | 2014-07-29 |