| NPI | 1699200972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: NE 112206) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IA A147627) |
| Enumeration Date | 2017-04-25 |
| Last Update Date | 2025-09-23 |