| NPI | 1255735254 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SC 30385) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: OH 16445) |
| Enumeration Date | 2014-10-20 |
| Last Update Date | 2025-10-27 |