| NPI | 1548734817 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: WA AP60966966) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2019-01-19 |
| Last Update Date | 2022-07-25 |