| NPI | 1215694997 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5015389) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NC COLO-3HJ1O) |
| Enumeration Date | 2021-11-17 |
| Last Update Date | 2022-12-16 |