| NPI | 1174139182 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 28243) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MS WILL-45YJ7O) |
| 363LF0000X Nurse Practitioner, Family (Licence: TN 211443) | |
| Enumeration Date | 2020-09-16 |
| Last Update Date | 2022-06-21 |