| NPI | 1124368303 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA SP033366) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: NY 306151) |
| Enumeration Date | 2013-02-25 |
| Last Update Date | 2026-01-03 |