| NPI | 1558859561 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3012290) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3012290) |
| Enumeration Date | 2018-04-25 |
| Last Update Date | 2023-04-13 |