| NPI | 1700612678 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: PA SP031360) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: PA RN680138) |
| Enumeration Date | 2024-09-09 |
| Last Update Date | 2024-12-03 |