| NPI | 1255946018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MS 904385) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MS 893703) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MS 893703) | |
| Enumeration Date | 2020-09-09 |
| Last Update Date | 2021-02-15 |