| NPI | 1003514142 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WA AP61372323) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: VA 0024185869) |
| Enumeration Date | 2023-02-17 |
| Last Update Date | 2023-02-17 |