| NPI | 1104626746 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LA2100X Nurse Practitioner, Acute Care (Licence: KY 3018479) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3018479) |
| 363LF0000X Nurse Practitioner, Family (Licence: KY 3018479) | |
| Enumeration Date | 2025-03-13 |
| Last Update Date | 2025-07-15 |