| NPI | 1619446812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MO 2018031757) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO 2018031757) |
| Enumeration Date | 2018-11-16 |
| Last Update Date | 2023-11-20 |