| NPI | 1194397265 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: GA RN240213) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WI 16812) |
| Enumeration Date | 2021-07-16 |
| Last Update Date | 2025-05-21 |