| NPI | 1720516966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WV APRN86703NP) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: KY 4043968) |
| 363LF0000X Nurse Practitioner, Family (Licence: KY 4043968) | |
| Enumeration Date | 2017-06-01 |
| Last Update Date | 2025-08-14 |