| NPI | 1093345860 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11015364) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL 9477332) |
| Enumeration Date | 2020-01-21 |
| Last Update Date | 2025-10-30 |