| NPI | 1265062541 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 27519) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MS 903792) |
| Enumeration Date | 2020-01-25 |
| Last Update Date | 2023-11-09 |