| NPI | 1639687627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SC 21464) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: SC 21464) |
| 363LF0000X Nurse Practitioner, Family (Licence: GA RN117539) | |
| Enumeration Date | 2018-01-12 |
| Last Update Date | 2024-11-11 |