| NPI | 1356754717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MT 158541) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WA 60475275) |
| Enumeration Date | 2014-06-03 |
| Last Update Date | 2024-04-03 |