| NPI | 1265303788 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OR 10063253) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: OR 202109568RN) |
| Enumeration Date | 2025-09-16 |
| Last Update Date | 2026-06-30 |