| NPI | 1720603558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner, Family (Licence: SC 26840) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: WA AP61041141) |
| Enumeration Date | 2020-06-08 |
| Last Update Date | 2023-02-01 |