| NPI | 1346819711 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 4000642) |
| Additional Taxonomies | 261QC1500X Clinic/Center, Community Health |
| 163W00000X Registered Nurse (Licence: KY 4000642) | |
| Enumeration Date | 2021-06-21 |
| Last Update Date | 2026-09-02 |