| NPI | 1336862150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 2022027673) |
| Additional Taxonomies | 261Q00000X Clinic/Center |
| Enumeration Date | 2022-09-26 |
| Last Update Date | 2025-04-01 |