| NPI | 1508247537 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11024713) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant |
| Enumeration Date | 2015-06-16 |
| Last Update Date | 2023-03-02 |