| NPI | 1023978392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: LA 245400) |
| Enumeration Date | 2025-11-17 |
| Last Update Date | 2026-04-20 |