| NPI | 1508603291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208VP0014X Pain Medicine, Interventional Pain Medicine (Licence: MI 4704425489) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX 1025352) |
| Enumeration Date | 2024-07-10 |
| Last Update Date | 2025-12-15 |