| NPI | 1255172862 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5023244) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NC 295448) |
| Enumeration Date | 2024-06-06 |
| Last Update Date | 2025-12-08 |