| NPI | 1588470256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: VA 24192218) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 824610) |
| Enumeration Date | 2024-12-09 |
| Last Update Date | 2025-01-15 |