| NPI | 1508471616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN11026741) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL RN9424066) |
| Enumeration Date | 2020-09-15 |
| Last Update Date | 2024-07-16 |