| NPI | 1346769742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MD R193830) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WV 104172) |
| Enumeration Date | 2017-09-18 |
| Last Update Date | 2024-01-25 |