| NPI | 1326737792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WY 59640) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2023-05-02 |
| Last Update Date | 2026-07-21 |