| NPI | 1063167815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KS 80991) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KS PENDING) |
| Enumeration Date | 2022-02-18 |
| Last Update Date | 2024-03-27 |