| NPI | 1518599935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11020638) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NE 88144) |
| 246ZC0007X Specialist/Technologist, Other Surgical Assistant (Licence: MN 4555) | |
| Enumeration Date | 2020-02-05 |
| Last Update Date | 2022-07-27 |