| NPI | 1104496983 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KS 53-79744-051) |
| Additional Taxonomies | 363LG0600X Nurse Practitioner, Gerontology (Licence: KS 79744) |
| Enumeration Date | 2021-06-25 |
| Last Update Date | 2024-04-05 |