| NPI | 1679161129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SC 27166) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WV 108116) |
| Enumeration Date | 2021-01-08 |
| Last Update Date | 2024-04-12 |