| NPI | 1114614872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LP2300X Nurse Practitioner, Primary Care (Licence: MS 906955) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MS 915744) |
| Enumeration Date | 2023-04-21 |
| Last Update Date | 2024-09-30 |