| NPI | 1073391553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: OR 10015019) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: AL 1-153747) |
| Enumeration Date | 2023-09-18 |
| Last Update Date | 2025-12-06 |