| NPI | 1215770516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 4047540) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: OH 0036149) |
| Enumeration Date | 2024-06-14 |
| Last Update Date | 2025-12-15 |