| NPI | 1710646120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QU0200X Clinic/Center, Urgent Care |
| Additional Taxonomies | 363LP2300X Nurse Practitioner, Primary Care (Licence: UT 9431214-4405) |
| 261QX0100X Clinic/Center, Occupational Medicine | |
| Enumeration Date | 2021-12-13 |
| Last Update Date | 2021-12-13 |