| NPI | 1174116438 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LG0600X Nurse Practitioner, Gerontology (Licence: NC 5014456) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: NC 2020093085) |
| Enumeration Date | 2021-02-18 |
| Last Update Date | 2025-04-10 |