| NPI | 1053980540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3016140) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KY 3016140) |
| Enumeration Date | 2021-06-21 |
| Last Update Date | 2023-11-13 |