| NPI | 1154791762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KS 53-76941-121) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO 2016034923) |
| Enumeration Date | 2015-09-25 |
| Last Update Date | 2026-04-24 |