| NPI | 1629675699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: UT 11985380-4405) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: WA AP61095878) |
| 363L00000X Nurse Practitioner (Licence: ID 2161573) | |
| 363LF0000X Nurse Practitioner, Family (Licence: UT 11985380-4405) | |
| Enumeration Date | 2020-10-02 |
| Last Update Date | 2026-04-15 |