| NPI | 1104301787 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 28871) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0001252049) |
| Enumeration Date | 2018-09-28 |
| Last Update Date | 2021-04-28 |