| NPI | 1295557130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 9538760) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: FL APRN11036395) |
| Enumeration Date | 2024-10-31 |
| Last Update Date | 2026-09-04 |