| NPI | 1124732417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NC 5022440) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NC 308500) |
| Enumeration Date | 2023-01-11 |
| Last Update Date | 2025-11-13 |