| NPI | 1790456465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: CA 95018505) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: CA 95018505) |
| 363LG0600X Nurse Practitioner, Gerontology (Licence: CA 95018505) | |
| Enumeration Date | 2021-09-23 |
| Last Update Date | 2025-11-15 |