| NPI | 1972384840 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CA 95026899) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CA 95192178) |
| Enumeration Date | 2023-10-09 |
| Last Update Date | 2023-11-22 |