| NPI | 1205585874 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SC 27865) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NC 5016262) |
| Enumeration Date | 2022-03-22 |
| Last Update Date | 2025-11-11 |