| NPI | 1912464074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95012206) |
| Additional Taxonomies | 163WR0006X Registered Nurse, Registered Nurse First Assistant (Licence: CA 674363) |
| Enumeration Date | 2019-02-25 |
| Last Update Date | 2021-10-29 |