| NPI | 1194456541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: PA SP028280) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: LA 226723) |
| 163W00000X Registered Nurse (Licence: LA RN161343) | |
| Enumeration Date | 2022-06-17 |
| Last Update Date | 2023-11-29 |