Individual
VI LY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DNP, CRNA
Contact information
Practice address
525 N WOLFE ST, BALTIMORE, MD 21205-2110
(410) 955-4766
Mailing address
4983 GRAND AVE, MONTCLAIR, CA 91763-6433
(909) 630-8038
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
R242988
MD
367500000X
Certified Registered Nurse Anesthetist
Primary
95002110
CA
Other
Enumeration date
06/28/2021
Last updated
03/31/2025
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