| NPI | 1063891893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2200X Nurse Practitioner, Adult Health (Licence: FL 11005730) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: NY 306583) |
| Enumeration Date | 2015-05-26 |
| Last Update Date | 2025-06-05 |