| NPI | 1003383381 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2025028133) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL APRN9497937) |
| Enumeration Date | 2018-10-25 |
| Last Update Date | 2025-08-05 |