| NPI | 1508538224 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA RN277778) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: SC APN.25135) |
| Enumeration Date | 2021-09-30 |
| Last Update Date | 2022-03-01 |