| NPI | 1114504040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: LA 219534) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: LA RN151655) |
| Enumeration Date | 2021-03-26 |
| Last Update Date | 2023-04-03 |