| NPI | 1548677461 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 34258) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NC 5022001) |
| 363LA2200X Nurse Practitioner, Adult Health (Licence: NY 306885) | |
| Enumeration Date | 2014-07-14 |
| Last Update Date | 2026-07-24 |