| NPI | 1700761152 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: FL APRN11043208) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: FL RN9641115) |
| Enumeration Date | 2025-08-06 |
| Last Update Date | 2025-11-06 |