| NPI | 1104541036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NM 70092) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NM 70092) |
| Enumeration Date | 2022-10-04 |
| Last Update Date | 2026-06-08 |