| NPI | 1720515257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: MO 2017017454) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: KS 53-78013-092) |
| Enumeration Date | 2017-05-15 |
| Last Update Date | 2024-11-22 |