| NPI | 1104457613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SC 25658) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: SC 241254) |
| Enumeration Date | 2020-02-03 |
| Last Update Date | 2024-05-22 |