| NPI | 1710505391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MS 904689) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: TN 28478) |
| Enumeration Date | 2020-07-09 |
| Last Update Date | 2025-03-06 |