| NPI | 1013624535 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: CT 0111887) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CT 011187) |
| Enumeration Date | 2022-11-03 |
| Last Update Date | 2023-01-10 |