| NPI | 1326730615 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363LG0600X Nurse Practitioner, Gerontology (Licence: OR 10045127) | 
| Additional Taxonomies | 363LG0600X Nurse Practitioner, Gerontology (Licence: NV 867330) | 
| Enumeration Date | 2023-05-24 | 
| Last Update Date | 2025-10-09 |