| NPI | 1164039988 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 65849) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: AZ 295437) |
| Enumeration Date | 2020-09-25 |
| Last Update Date | 2024-07-31 |