| NPI | 1215712500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NM 57636) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NM 57636) |
| Enumeration Date | 2023-08-28 |
| Last Update Date | 2024-08-09 |