| NPI | 1326925090 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL APRN11033649) | 
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TX 1046941) | 
| 207Q00000X Family Medicine (Licence: KY 4045371) | |
| Enumeration Date | 2025-08-16 | 
| Last Update Date | 2025-08-16 |