| NPI | 1386275840 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 11006289) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL XXXXXX) |
| 261QP2300X Clinic/Center, Primary Care | |
| Enumeration Date | 2020-02-03 |
| Last Update Date | 2022-09-09 |