| NPI | 1558980904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: PA SP026026) |
| Additional Taxonomies | 213E00000X Podiatrist (Licence: PA SC002003L) |
| Enumeration Date | 2020-04-15 |
| Last Update Date | 2024-12-26 |