| NPI | 1689331373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: KY 3017048) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: KY 1175148) |
| 363LF0000X Nurse Practitioner, Family (Licence: KY 3017048) | |
| Enumeration Date | 2021-11-17 |
| Last Update Date | 2022-12-19 |