| NPI | 1003542127 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: KS 53-81411-011) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: MO 2022022667) |
| Enumeration Date | 2022-07-29 |
| Last Update Date | 2022-10-06 |