| NPI | 1134738172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3017196) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WA 61087945) |
| Enumeration Date | 2020-07-27 |
| Last Update Date | 2025-12-10 |