| NPI | 1235612771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN9392136) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: FL ALLERGYTRAINED) |
| Enumeration Date | 2018-09-11 |
| Last Update Date | 2025-09-24 |