| NPI | 1700447562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NC 5011896) |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: NC 5011896) |
| Enumeration Date | 2019-06-24 |
| Last Update Date | 2023-11-27 |