| NPI | 1104463819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2100X Nurse Practitioner, Acute Care (Licence: GA RN292038) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: GA RN292038) |
| 163W00000X Registered Nurse (Licence: TX 876479) | |
| 363LA2100X Nurse Practitioner, Acute Care (Licence: GA Pending) | |
| Enumeration Date | 2019-12-02 |
| Last Update Date | 2021-09-14 |