| NPI | 1376949917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 9245612) |
| Additional Taxonomies | 261Q00000X Clinic/Center (Licence: FL 9245612) |
| Enumeration Date | 2014-11-10 |
| Last Update Date | 2024-06-13 |