| NPI | 1255075149 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL 11019298) |
| 163W00000X Registered Nurse (Licence: FL 9523373) | |
| Enumeration Date | 2022-04-26 |
| Last Update Date | 2025-04-08 |