| NPI | 1083163042 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11010462) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: GA RN148874) |
| Enumeration Date | 2016-09-30 |
| Last Update Date | 2024-03-20 |