| NPI | 1497109730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: OR 201702479NP-PP) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NY 340594) |
| Enumeration Date | 2016-04-22 |
| Last Update Date | 2026-04-07 |