| NPI | 1548838055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11012519) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL 11012519) |
| Enumeration Date | 2021-06-12 |
| Last Update Date | 2026-08-12 |