| NPI | 1124704796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP2300X Nurse Practitioner Primary Care (Licence: NC LAKE-2S9JB) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NC LAKE-2S9JB) |
| Enumeration Date | 2023-06-27 |
| Last Update Date | 2023-10-05 |