| NPI | 1174007991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN9274333) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL 2018020752) |
| Enumeration Date | 2018-09-18 |
| Last Update Date | 2022-03-04 |