| NPI | 1205498193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 55755) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: ID 55755) |
| Enumeration Date | 2019-07-01 |
| Last Update Date | 2024-04-17 |