| NPI | 1679350011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: PA SP031689) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: NJ 26NR27228800) |
| Enumeration Date | 2023-09-11 |
| Last Update Date | 2025-08-11 |