| NPI | 1003411232 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 11011747) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL RN9216433) |
| Enumeration Date | 2020-12-04 |
| Last Update Date | 2021-08-16 |