| NPI | 1649118654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 4061277) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: KY 1163731) |
| Enumeration Date | 2026-03-23 |
| Last Update Date | 2026-07-31 |