| NPI | 1679235808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: AZ 265209) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: AZ 265209) |
| 363LP0200X Nurse Practitioner, Pediatrics (Licence: AZ 265209) | |
| Enumeration Date | 2021-10-05 |
| Last Update Date | 2025-08-08 |