| NPI | 1356890933 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: FL APRN11023584) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: RI APRN01457) |
| Enumeration Date | 2016-09-23 |
| Last Update Date | 2023-10-13 |