| NPI | 1295480630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 31166) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MS 905299) |
| Enumeration Date | 2022-02-15 |
| Last Update Date | 2023-11-09 |