| NPI | 1134899800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251T00000X PACE Provider Organization (Licence: CO 0996511) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: CO 0996511) |
| 363LG0600X Nurse Practitioner, Gerontology (Licence: CO 0996511) | |
| 363LP2300X Nurse Practitioner, Primary Care (Licence: CO 0996511) | |
| Enumeration Date | 2021-09-15 |
| Last Update Date | 2024-10-08 |