| NPI | 1104490218 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NC 5016607) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: PA SP024387) |
| Enumeration Date | 2021-05-14 |
| Last Update Date | 2023-02-14 |