| NPI | 1639056948 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC AG08250029) |
| Additional Taxonomies | 363LA2200X Nurse Practitioner, Adult Health (Licence: NC AG08250029) |
| Enumeration Date | 2025-08-19 |
| Last Update Date | 2025-08-19 |