| NPI | 1053928804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: TN 30000) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11009348) |
| Enumeration Date | 2020-09-25 |
| Last Update Date | 2023-09-05 |