| NPI | 1265047484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MS 903964) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: MS 906964) |
| Enumeration Date | 2020-09-14 |
| Last Update Date | 2025-08-05 |