| NPI | 1003495565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: UT 9045507-4405) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NV 849734) |
| Enumeration Date | 2021-04-02 |
| Last Update Date | 2023-08-01 |