| NPI | 1104547710 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: OR 10031759) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL 11021175) |
| Enumeration Date | 2022-09-12 |
| Last Update Date | 2026-06-29 |