| NPI | 1013612720 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11025455) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: FL APRN11025455) |
| Enumeration Date | 2023-04-03 |
| Last Update Date | 2026-07-14 |