| NPI | 1487124566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN11000578) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL 9389369) |
| Enumeration Date | 2018-11-30 |
| Last Update Date | 2026-04-08 |