| NPI | 1023877453 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WY 54063) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: CO 0999558) |
| Enumeration Date | 2024-03-18 |
| Last Update Date | 2024-12-13 |