| NPI | 1659110252 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NM 79126) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: CT 14594) |
| Enumeration Date | 2024-05-22 |
| Last Update Date | 2025-04-01 |