| NPI | 1275188856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NE 112912) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IA H172961) |
| Enumeration Date | 2019-08-09 |
| Last Update Date | 2023-05-25 |