| NPI | 1346542867 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MT 102425) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: MT NUR-APRN-LIC-102425) |
| Enumeration Date | 2010-12-04 |
| Last Update Date | 2025-02-11 |