| NPI | 1306242128 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 9263261) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN9263261) |
| Enumeration Date | 2014-11-05 |
| Last Update Date | 2023-01-11 |