| NPI | 1043965981 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: NC 5016054) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NC 2020010649) |
| Enumeration Date | 2022-02-18 |
| Last Update Date | 2022-04-13 |