| NPI | 1164103628 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: PA SP028198) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CT 12163) |
| Enumeration Date | 2023-07-27 |
| Last Update Date | 2023-09-28 |