| NPI | 1609619899 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC AG07250044) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NC ROAX34E4) |
| Enumeration Date | 2024-06-14 |
| Last Update Date | 2025-08-28 |