| NPI | 1699330456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KS 53-78711-042) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: MO 2019007958) |
| Enumeration Date | 2019-05-07 |
| Last Update Date | 2025-02-19 |