| NPI | 1912205204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95003557) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL ARNP9264808) |
| Enumeration Date | 2011-03-10 |
| Last Update Date | 2017-04-07 |