| NPI | 1457057671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11024468) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL F01231161) |
| Enumeration Date | 2023-01-31 |
| Last Update Date | 2024-10-02 |