| NPI | 1114418878 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 9455497) |
| Additional Taxonomies | 363LP0200X Nurse Practitioner, Pediatrics (Licence: FL APRN9455497) |
| Enumeration Date | 2018-05-29 |
| Last Update Date | 2025-04-09 |