| NPI | 1053911339 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: LA 215856) | 
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: LA 215856) | 
| Enumeration Date | 2020-10-27 | 
| Last Update Date | 2023-02-28 |