| NPI | 1558987792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 11007737) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TX 1151424) |
| Enumeration Date | 2020-06-23 |
| Last Update Date | 2025-04-14 |