| NPI | 1659967370 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11010533) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: FL 11010533) |
| Enumeration Date | 2020-12-16 |
| Last Update Date | 2022-11-01 |