| NPI | 1003629445 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KS 53-83870-082) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO 2026001760) |
| Enumeration Date | 2025-01-29 |
| Last Update Date | 2026-04-15 |