| NPI | 1679341291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: FL 11030142) |
| Additional Taxonomies | 207QA0505X Family Medicine, Adult Medicine (Licence: FL 11030142) |
| Enumeration Date | 2023-12-13 |
| Last Update Date | 2025-12-18 |