| NPI | 1194579169 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11031934) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL APRN11031934) |
| Enumeration Date | 2024-04-15 |
| Last Update Date | 2025-11-24 |