| NPI | 1083192975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OH APRN.CNP.0030126) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: PA SP019049) |
| Enumeration Date | 2018-08-01 |
| Last Update Date | 2025-05-29 |