| NPI | 1063187128 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: GA GAA-NP-000179) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11012338) |
| Enumeration Date | 2021-08-11 |
| Last Update Date | 2021-08-11 |