| NPI | 1043028111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA RN186286) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: GA 2023154542) |
| Enumeration Date | 2024-12-20 |
| Last Update Date | 2025-05-19 |