| NPI | 1528820123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SD CP003133) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IA A177592) |
| Enumeration Date | 2024-01-29 |
| Last Update Date | 2024-11-22 |