| NPI | 1104703222 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: PR 99242) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: PR 99242) |
| Enumeration Date | 2025-08-20 |
| Last Update Date | 2025-08-20 |