| NPI | 1629540950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3012992) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3012992) |
| Enumeration Date | 2018-12-27 |
| Last Update Date | 2024-01-22 |