| NPI | 1053904896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: KY 3015217) |
| Additional Taxonomies | 163WE0003X Registered Nurse Emergency (Licence: KY 1102450) |
| Enumeration Date | 2021-02-12 |
| Last Update Date | 2022-03-17 |