| NPI | 1124973623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: ID 2871990) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WA 70100432) |
| Enumeration Date | 2026-03-02 |
| Last Update Date | 2026-06-02 |