| NPI | 1104548221 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: PA SP026270) |
| Additional Taxonomies | 363LG0600X Nurse Practitioner, Gerontology (Licence: PA SP026270) |
| Enumeration Date | 2022-09-15 |
| Last Update Date | 2022-11-14 |