| NPI | 1134687536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 4019014) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: TX 1114090) |
| Enumeration Date | 2019-03-05 |
| Last Update Date | 2024-09-13 |