| NPI | 1154059061 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2022036415) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO F05220729) |
| Enumeration Date | 2022-08-09 |
| Last Update Date | 2026-03-06 |