| NPI | 1114370418 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: LA AP08855) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: LA AP08855) |
| Enumeration Date | 2016-07-21 |
| Last Update Date | 2026-04-15 |