| NPI | 1558046565 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SC 30267) | 
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NC 5018281) | 
| 363LA2100X Nurse Practitioner, Acute Care (Licence: NC 5018281) | |
| Enumeration Date | 2023-06-19 | 
| Last Update Date | 2025-09-15 |