| NPI | 1093496069 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: AZ 295726) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: GU 100460) |
| Enumeration Date | 2023-07-31 |
| Last Update Date | 2025-06-12 |