| NPI | 1629899984 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11036267) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: FL 2024084788) |
| Enumeration Date | 2024-10-21 |
| Last Update Date | 2024-11-19 |