| NPI | 1457968315 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11009524) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL RN9504856) |
| Enumeration Date | 2020-09-25 |
| Last Update Date | 2020-10-07 |