| NPI | 1225676901 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11005311) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KY 4030940) |
| Enumeration Date | 2019-12-13 |
| Last Update Date | 2025-03-06 |