| NPI | 1609584960 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NC 5021560) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: VA 0024185720) |
| Enumeration Date | 2022-11-07 |
| Last Update Date | 2025-04-12 |