| NPI | 1497542773 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA RN296180) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner Family (Licence: TX 1193193) |
| 163W00000X Registered Nurse (Licence: GA 296180) | |
| Enumeration Date | 2025-04-22 |
| Last Update Date | 2025-06-17 |