| NPI | 1104311505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: IA A130196) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IA A130196) |
| Enumeration Date | 2018-06-27 |
| Last Update Date | 2024-01-04 |