| NPI | 1639636772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WV 0024177296) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0024177296) |
| 363LF0000X Nurse Practitioner, Family (Licence: VA 00241177296) | |
| Enumeration Date | 2019-02-25 |
| Last Update Date | 2024-02-07 |