| NPI | 1356206650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11047813) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: CO RN.1641150) |
| Enumeration Date | 2025-12-18 |
| Last Update Date | 2026-07-27 |