| NPI | 1619647021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5019243) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL 11015431) |
| Enumeration Date | 2021-09-16 |
| Last Update Date | 2024-08-05 |