| NPI | 1003453424 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LG0600X Nurse Practitioner, Gerontology (Licence: SC 22900) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: SC 22900) |
| Enumeration Date | 2019-12-04 |
| Last Update Date | 2022-04-13 |