| NPI | 1245777291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: VA 0001151127) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0001151127) |
| Enumeration Date | 2017-01-30 |
| Last Update Date | 2025-09-17 |