| NPI | 1720658529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: WI 11083) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: WI 236137) |
| Enumeration Date | 2021-06-25 |
| Last Update Date | 2026-05-19 |