| NPI | 1083409676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: GA RN215030) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: GA RN215030) |
| Enumeration Date | 2025-04-14 |
| Last Update Date | 2025-08-22 |