| NPI | 1679219752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: SC 30537) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: VT 026.0126294) |
| Enumeration Date | 2022-05-11 |
| Last Update Date | 2025-10-08 |