| NPI | 1194237974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WV 117852) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN9350693) |
| Enumeration Date | 2017-11-01 |
| Last Update Date | 2025-10-02 |