| NPI | 1407629801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: WV 72475) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WV 117843) |
| Enumeration Date | 2023-11-07 |
| Last Update Date | 2023-11-07 |