| NPI | 1295154094 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN11010128) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL 645037) |
| 363LF0000X Nurse Practitioner, Family (Licence: FL F07201323) | |
| Enumeration Date | 2014-04-09 |
| Last Update Date | 2021-04-19 |