| NPI | 1669942173 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL APRN11000559) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL RN3422732) |
| Enumeration Date | 2018-11-27 |
| Last Update Date | 2026-09-05 |