| NPI | 1235611591 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11013803) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL RN9220945) |
| Enumeration Date | 2018-09-04 |
| Last Update Date | 2025-10-07 |