| NPI | 1639923667 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL 11024092) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL f12220196) |
| Enumeration Date | 2024-04-16 |
| Last Update Date | 2024-05-01 |