| NPI | 1962029637 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: CA 95013722) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: CA 95013722) |
| Enumeration Date | 2020-06-29 |
| Last Update Date | 2021-09-16 |