| NPI | 1568856102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: GA RN298621) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NY 339413) |
| Enumeration Date | 2015-03-21 |
| Last Update Date | 2021-10-21 |