| NPI | 1124557236 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3011374) |
| Additional Taxonomies | 261QU0200X Clinic/Center, Urgent Care (Licence: KY 3011374) |
| Enumeration Date | 2017-06-12 |
| Last Update Date | 2023-03-07 |