| NPI | 1073257424 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 50168188) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NC SLUS-SCCU6) |
| 163W00000X Registered Nurse (Licence: NC 267026) | |
| Enumeration Date | 2022-04-22 |
| Last Update Date | 2022-07-22 |