| NPI | 1003555624 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: LA 226191) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: LA RN154204) |
| Enumeration Date | 2022-06-01 |
| Last Update Date | 2024-05-28 |