| NPI | 1619656147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: TN 34302) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: GA RN281594) |
| Enumeration Date | 2023-07-12 |
| Last Update Date | 2024-11-04 |