| NPI | 1720612872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363LF0000X Nurse Practitioner Family (Licence: FL APRN11012229) |
| Additional Taxonomies | 163WC1500X Registered Nurse Community Health (Licence: FL RN9525076) |
| Enumeration Date | 2020-02-27 |
| Last Update Date | 2022-12-22 |