| NPI | 1245017375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2200X Nurse Practitioner Adult Health (Licence: ID 61448) |
| Additional Taxonomies | 363LG0600X Nurse Practitioner Gerontology (Licence: ID 61448) |
| Enumeration Date | 2023-09-12 |
| Last Update Date | 2024-04-14 |