| NPI | 1639763105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LA2100X Nurse Practitioner, Acute Care (Licence: TN 30285) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2021-02-25 |
| Last Update Date | 2021-11-17 |