| NPI | 1265148019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024186509) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: CO 1653857) |
| 363L00000X Nurse Practitioner (Licence: VA 0024186509) | |
| Enumeration Date | 2023-01-25 |
| Last Update Date | 2023-02-22 |