| NPI | 1710721402 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: VA 0024190668) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: VA 0001324781) |
| Enumeration Date | 2024-06-19 |
| Last Update Date | 2024-07-05 |