| NPI | 1114585890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2021009742) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KS 53-78770-011) |
| Enumeration Date | 2019-05-29 |
| Last Update Date | 2024-10-10 |