| NPI | 1104471796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: OH APRN.CNP.0040016) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: OH 4704377060) |
| Enumeration Date | 2019-08-09 |
| Last Update Date | 2026-04-09 |