| NPI | 1306507066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN11017955) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL 9357816) |
| Enumeration Date | 2022-01-05 |
| Last Update Date | 2026-02-06 |