| NPI | 1104468560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: OK R0134650) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: OK 134650) |
| Enumeration Date | 2019-10-16 |
| Last Update Date | 2025-02-21 |