| NPI | 1073925319 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2025017576) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: AZ AP5594) |
| Enumeration Date | 2014-05-21 |
| Last Update Date | 2025-08-14 |