| NPI | 1689217911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: GA 12647) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA1806) |
| 363AM0700X Physician Assistant Medical (Licence: ID PA1806) | |
| 363AM0700X Physician Assistant Medical (Licence: GA 12647) | |
| Enumeration Date | 2019-10-18 |
| Last Update Date | 2024-10-30 |