| NPI | 1417470824 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WV 75939) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: WV 75939) |
| Enumeration Date | 2017-07-18 |
| Last Update Date | 2024-09-30 |