| NPI | 1669139036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SC 25222) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: GA GAA-NP000484) |
| Enumeration Date | 2021-11-20 |
| Last Update Date | 2023-02-17 |