| NPI | 1245076801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN1047670) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL RN9604438) |
| Enumeration Date | 2024-07-03 |
| Last Update Date | 2026-06-05 |