| NPI | 1366858946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5006955) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: SC 30345) |
| Enumeration Date | 2014-07-03 |
| Last Update Date | 2025-12-18 |