| NPI | 1396256616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: FL 9359202) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VA 0024175496) |
| Enumeration Date | 2017-10-12 |
| Last Update Date | 2023-10-11 |