| NPI | 1407599251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 20230080819) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KS 81207) |
| 163W00000X Registered Nurse (Licence: KS 147999) | |
| Enumeration Date | 2022-04-19 |
| Last Update Date | 2026-01-07 |