| NPI | 1710572466 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: KY 3015851) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 3015851) |
| Enumeration Date | 2021-03-04 |
| Last Update Date | 2026-04-10 |