| NPI | 1407509763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MD R268289) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: TX 1023565) |
| Enumeration Date | 2022-01-27 |
| Last Update Date | 2024-08-14 |