| NPI | 1336265487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: IA A175174) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO 100229) |
| Enumeration Date | 2007-03-21 |
| Last Update Date | 2024-01-03 |