| NPI | 1023993821 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208VP0000X (Licence: FL 0000000000) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KS 0000000000) |
| Enumeration Date | 2025-08-11 |
| Last Update Date | 2025-08-11 |