| NPI | 1588032817 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA RN191921) | 
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: SC 206900) | 
| Enumeration Date | 2015-09-03 | 
| Last Update Date | 2023-07-26 |