| NPI | 1215642673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: CT 11416) |
| Additional Taxonomies | 207R00000X Internal Medicine (Licence: CT 11416) |
| Enumeration Date | 2023-01-20 |
| Last Update Date | 2025-12-04 |