| NPI | 1154953107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MS 903739) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: TN 27083) |
| Enumeration Date | 2020-02-07 |
| Last Update Date | 2026-09-23 |