| NPI | 1134737265 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5021113) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA F07200715) |
| 363LF0000X Nurse Practitioner, Family (Licence: VA 0024179964) | |
| Enumeration Date | 2020-07-15 |
| Last Update Date | 2024-12-31 |