| NPI | 1124963608 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11048113) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL 9366609) |
| Enumeration Date | 2026-04-21 |
| Last Update Date | 2026-06-12 |