| NPI | 1124796594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3016748) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KY 3016748) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-09-01 |
| Last Update Date | 2021-11-08 |