| NPI | 1336654623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5010689) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NC 222304) |
| Enumeration Date | 2017-12-08 |
| Last Update Date | 2025-01-24 |