| NPI | 1104634542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: MT 264408) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MT 264408) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2024-12-18 |
| Last Update Date | 2025-06-26 |