| NPI | 1487372512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SC 28948) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: GA RN245123) |
| Enumeration Date | 2022-08-15 |
| Last Update Date | 2025-05-20 |