| NPI | 1073395125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 39994) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TN 242525) |
| Enumeration Date | 2023-10-13 |
| Last Update Date | 2025-10-14 |