| NPI | 1225538978 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11040076) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: FL 17-459) |
| Enumeration Date | 2018-02-20 |
| Last Update Date | 2025-06-24 |