| NPI | 1619583010 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SD CP002499) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: IA Pending) |
| Enumeration Date | 2020-09-21 |
| Last Update Date | 2023-01-31 |