| NPI | 1104434703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5013366) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NC 5013366) |
| Enumeration Date | 2020-07-20 |
| Last Update Date | 2024-08-02 |