| NPI | 1679087605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: AK 252458) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: AK 188881) |
| Enumeration Date | 2017-11-29 |
| Last Update Date | 2026-04-24 |