| NPI | 1144046301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 1071540) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: OR 10036869) |
| Enumeration Date | 2024-12-03 |
| Last Update Date | 2025-01-02 |