| NPI | 1639552060 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MO 2022021642) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MO 2012033477) |
| Enumeration Date | 2015-07-02 |
| Last Update Date | 2025-03-18 |