| NPI | 1003376328 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN11001964) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL RN9343192) |
| Enumeration Date | 2019-03-22 |
| Last Update Date | 2026-03-11 |