| NPI | 1356124432 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: ID 77350) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WA AP61475320) |
| Enumeration Date | 2023-08-14 |
| Last Update Date | 2023-09-26 |