| NPI | 1114590080 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IN 71011655A) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3016373) |
| Enumeration Date | 2021-07-20 |
| Last Update Date | 2022-01-03 |