| NPI | 1346960085 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WY 50795) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: UT 6200065-4405) |
| Enumeration Date | 2022-09-01 |
| Last Update Date | 2024-03-27 |