| NPI | 1417311622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11012299) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL 15-528) |
| Enumeration Date | 2016-04-13 |
| Last Update Date | 2021-04-05 |